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Winning Abstract from the 2007 Medical Student Abstract Competition: Neutropenic Fever and Thrombocytopenia in a Returning Traveler.

Ryan Hollenbeck, University of Iowa Carver College of Medicine

Tropical diseases are rarely seen in the Midwest, and fever in the returning traveler often poses a significant diagnostic challenge.

Case Presentation
A 26-year-old male medical student presented to the student health department four days after returning from the Riviera Maya on Mexico's Yucatan Peninsula. Two days prior to presentation he began to experience severe abdominal cramping and watery diarrhea. He was given ciprof1oxacin as empiric treatment for traveler's diarrhea, which resolved that day. On the morning of presentation he became symptomatic with chills, fevers to 104F, severe myalgias, and burning eye pain. Physical exam was unremarkable except for diffuse nontender lymphadenopathy. Complete blood count revealed leukocytopenia, thrombocytopenia, and neutropenia. Blood cultures, stool cultures, stool ova and parasite, and malaria thin and thick smears were negative. Electrolytes, BUN, creatinine, and liver function tests were all within normal limits. He was treated with ceftriaxone for suspected enteroinvasive bacterial infection and sent home. Over the course of the three days following presentation he continued to experience intermittent fevers from 101-103F despite receiving ceftriaxone infusions daily. His leukocyte, platelet, and neutrophil counts continued to drop. He was hospitalized for neutropenic fever of unknown origin. The differential diagnosis included typhoid fever, enteroinvasive salmonella, shigella, campylobacter, or yersinia, EBV mononucleosis, CMV, dengue fever, and ehrlichiosis. He was treated with cefepime and doxycycline. The fevers abruptly stopped on the second day of hospitalization, his blood counts began to normalize, and he was discharged feeling well. Serologic tests were significant for reactive heterophile antibody, CMV and EBV serologies consistent with past exposure and no acute infection, negative ehrlichia serologies, and strongly positive dengue fever IgM. The diagnosis of dengue fever was confirmed.

Dengue fever is an acute febrile viral disease caused by one of four serotypes of f1avivims transmitted by the Aedes aegypti mosquito. The acute infection is characterized by headaches, GI disturbances, myalgias, arthralgias, prostration, lymphadenopathy, leukocytopenia, high fever, and retroorbital eye pain. Dengue fever is the most significant arthropod-born viral disease worldwide, found in over 100 countries and causing 50-100 million cases of infection annually. However, the patient described represents only the second confirmed case in Iowa since 2001 . This case illustrates several important points including the classic signs and symptoms of dengue fever, the diagnostic challenge posed by diseases not endemic to an area, and the spreading epidemic of dengue fever in the tropics.

Back to March 2008 Issue of IMpact

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